Medical Claims Investigator

Job Summary

A company is looking for a Medical Claims Investigator.

Key Responsibilities

• Review medical paid claims against provider contracts and policies for accuracy
• Utilize analytics and data mining techniques to analyze hospital and physician claims
• Evaluate medical claims for coding and pricing errors using HCPCS, ICD-10, and CPT codes

Required Qualifications

• Minimum high school diploma or GED with two years of experience in medical claims investigation or data mining
• Knowledge of coding type edits and medical claim reimbursement methodologies
• Proficiency with medical terminology and medical procedures
• Experience with coding guidelines and federal/state regulations related to coding and billing
• Familiarity with automated medical claims payment systems and advanced computer skills